Anxiety disorder and anxiolytic pharmacotherapy during pregnancy: The impact on pregnancy outcomes

OBJECTIVE: This study determines the contributions of anxiety disorder and anxiolytic pharmacotherapy on perinatal outcomes and examines prescribing trends during pregnancy. METHODS: A retrospective cohort study was conducted at a single tertiary medical center between 2013 and 2024. Women were classified into three groups: no anxiety, unmedicated anxiety, and medicated anxiety. The primary outcome was a composite of preterm birth, Apgar score below 7 at 5 min, or neonatal intensive care unit admission. Secondary outcomes included preeclampsia and prolonged hospital stay. Multivariable models were adjusted for pre-specified maternal and obstetric confounders. RESULTS: Overall, 142 028 singleton deliveries were included: 136563 (96.2%) with no anxiety, 942 (0.7%) with unmedicated anxiety, and 4523 (3.2%) with medicated anxiety. Anxiolytic prescribing nearly doubled from 2.25% in 2013 to 4.13% in 2024 (Cochran-Armitage Z = 13.287, P < 0.001). Both anxiety groups showed significantly higher odds of the composite outcome compared with no anxiety: unmedicated anxiety adjusted odds ratio (aOR) 1.615 (95% confidence interval [CI] 1.227-2.088) and medicated anxiety aOR 1.685 (95% CI 1.491-1.897). Direct comparison of medicated against unmedicated women revealed no significant difference in any outcome. Preeclampsia was the only outcome where medicated women showed significantly lower odds than unmedicated women (aOR 0.674, 95% CI 0.471-0.981). CONCLUSION: Anxiety disorder during pregnancy was associated with adverse perinatal outcomes regardless of pharmacological treatment status. No significant outcome differences were observed between treated and untreated women. However, because anxiety severity, timing and duration of treatment, and medication adherence were unavailable, these findings should not be interpreted as evidence regarding the safety or causal effects of pharmacological treatment.